PTSA Application Form

Please note that the PTSA liability insurance plan runs from January 1 to January 1 each year. Any plan purchased after January 1 will not be back dated and prices will NOT be pro-rated.

Renewals are available from November 1 through until January 1 each year. If you are renewing, please select the “Renewal” option from the application type below.

Application Type

Please select the type of application you are submitting below:

New ApplicationChoose this option for coverage starting immediately, or if you are a new applicant that does not have current coverage.

Renewal ApplicationChoose this option if you are an existing member that is renewing coverage for next term, or if you do not require coverage until January 1.

Application Type

General Information

Current Date

February 22, 2018

First Name

Last Name

Email Address

Telephone

Business Phone

Fax

Address

City

Province

Postal Code

Membership Number

Additional Information

In the past, has the Applicant or any of his/her employees ever been the recipient of any allegations of professional negligence in writing or verbally?

Is the Applicant or any of his/her employees aware of any facts, circumstances or situations which may reasonably give rise to a claim, other than as advised above?

Has insurance coverage ever been declined or cancelled or the renewal thereof been refused?

WITHOUT LIMITATION OF ANY OTHER REMEDY AVAILABLE TO THE INSURER, IT IS AGREED THAT IF THERE BE KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION, ANY CLAIM OR ACTION SUBSEQUENTLY EMANATING THEREFROM IS EXCLUDED FROM COVERAGE UNDER THE PROPOSED INSURANCE.

Limits Requested

Please indicate limits required

Premium

Professional Liability

$100

$1,000,000 per loss/$1,000,000 per policy period

$125

$2,000,000 per loss/$2,000,000 per policy period

$140

$2,000,000 per loss/$4,000,000 per policy period

$150

$5,000,000 per loss/$5,000,000 per policy period

Applicant's consent to the transmission of the information contained in the application form

I hereby acknowledge that the information collected in the Application form is acquired by my insurance broker to be transmitted to ENCON Group Inc. for the sole purpose of obtaining an insurance policy, and will be kept confidential.

Moreover, I authorize ENCON Group Inc., its insurers or service Providers to:

- conduct verification, using outside sources, of the information contained in the Application form, in attached documentation and in subsequently provided documentation;

- in the event of a claim, transmit the submitted and verified information to loss adjusters, lawyers or other similar offices for the purposes of investigating, defending, negotiating or settling any claims, as required.

Declarations and Signature

By submitting this application for insurance, the applicant declares that, to the best of his/her knowledge and belief, the statements set forth herein are true and correct and that reasonable efforts have been made to obtain sufficient information to facilitate the proper and accurate completion of this Application form. The applicant further agrees that if any significant change in the condition of the Applicant is discovered between the date of this Application form and the effective date of the policy, which would render this Application form inaccurate or incomplete, notice of such change will be reported immediately in writing to the Insurance Manager.

Although submission of this Application form does not bind the Applicant to Purchase the insurance, the Applicant agrees that this form and the information furnished pursuant hereto shall be the basis of the contract should a policy be issued and this form will become part of the policy.

It is also agreed that should a policy be issued, it is understood that eligibility for this program is contingent upon membership in good standing in the Pharmacy Technician Society of Alberta.

I have read and agree to the terms listed above, and verify all information is correct.

Life Insurance, Quick & Easy

Manulife Financial and HDF Insurance are making it even easier to get the Life Insurance protection you want and need. Starting immediately, the application process for TERM Life Insurance policies has been made easier and less invasive. For policies up to $1 million, blood and urine samples are no longer required. As well, you will not be visited by a nurse. Only a meeting with your HDF Insurance advisor and a telephone interview from a Manulife professional are all that's required. This promotion is open to those up to 45 years of age and is available on all TERM policies up to $1 million of Life Insurance coverage.

For a free quotation and/or assist on completing an application, please contact: